What is a SOAP Note?
SOAP is an acronym where each letter stands for a word. Just about every one in a medical office should
know what a SOAP note is and how it is to be written. Health care providers often use the SOAP note format to
standardize medical evaluation entries made in patient records. What follows are SOAP note charting
examples and how information is properly documented in a medical record.
The letters S, O, A, and P stand for SUBJECTIVE,OBJECTIVE, ASSESSMENT and PLAN. The SOAP note
improves communication between all caring for the patient. It displays the assessment, problems and plans in
an organized format and facilitates better medical care when used. Medical documentation of patient
complaints and treatment must be consistent, concise and comprehensive. It is important that everything that
needs to be documented in a patient's chart is entered promptly, precisely and in the right format and most
importantly, in accordance with your medical office's standards and rules and within the legal parameters.
Charting Examples - What the Medical Assistant Writes
A medical assistant can write only the "S-part" (subjective observations) and "O-part" (objective observations).
Typical entries are simple statements, phrases and values for the doctor, such as:
❖ Chief Complaint (CC): Patient complains of wrist pain x 3 days
❖ Location (example: right hand)
❖ Quality (example: Pt. states aching, burning, radiating pain)
❖ Severity (example: ache in left wrist, 5 on a scale of 1 - 10)
❖ Duration (example: started two days ago)
❖ Timing (example: constant, or comes and goes)
❖ Context (example: lifted large object at work)
❖ Modifying factors (example: better when an ice pack is applied)
❖ Associated signs and symptoms (example: numbness in ring finger)
SOAP Note Content
SOAP notes can be flexible. The content of the note will differ for each specialty and likely you will develop your
own style as you try to accommodate your doctor's and office preferences. The note written by a novice will
usually turn out to be a little longer than that of staff with more clinical judgment and experience in proper SOAP
note writing format. The SOAP note should briefly express the following:
❖ date and purpose of the visit
❖ S: patient’s symptoms and complaints
❖ O: patient's height, weight, temperature, pulse, blood pressure, visual acuity, etc.
❖ A: new lab data and results of studies, reports, assessments
❖ P: the current formulation and plan for the patient
SOAP Note Length
The SOAP note is NOT supposed to be as detailed as a progress report. Complete sentences are not
necessary and abbreviations are appropriate, however, avoid them until you have a handle on how the
abbreviations are used-often they differ for each specialty but are consistent within the medical office where
you work. The hidden pitfalls of using abbreviations is that while your office may be familiar with their meaning
an outside physician may not understand your abbreviations.
Writing the SOAP Note
More is not always better, so keep it short. An inexperienced SOAP note writer will often give more thought as
to what to write and wind up putting more to paper than is actually necessary. A short, but precise SOAP note
is better than an entry that is too verbose. As you experiment and become more proficient in your routine you
will eventually develop your best technique to remain short and accurate. It is practice that makes perfect.
Always remember while documenting that the patient's medical record is a legal document, whatever is
charted must be accurate and whatever wasn't, never happened! Under certain circumstances corrections are
permissible. An omission of vital information, or an error in the note can become detrimental to the patient's
health. Any corrections, even long after the fact, must be clearly marked as such, initialed and dated.
SOAP Note Exercise - Corrected
Institute in 1998. Here is my SOAP Note Writing exercise corrected by the instructor.